HEADACHE SYNDROME in patients with various ages

Education

1. HEADACHE SYNDROMES . PRESENTATION BY BARNABAS

2. 2 Introduction Definition : A headache is a pain or discomfort in the head , scalp , or neck One of the most common of all human physical complaints. Headache is actually a symptom rather than a disease a stress response, vasodilation (migraine),skeletal muscle tension (tension headache), or a combination of factors.

3. 3 Worldwide problem Up to 25% of adults have a severe headache each year Up to 4% have daily or near-daily headache Lifetime prevalence: 90% or more Significant suffering and economic loss

4. 4 Classification PRIMARY HEADCHE A headache that is not caused by another underlying disease, trauma or medical condition. Accounts for about ninety percent of all headaches.

5. 5 Intrinsic dysfunction of the nervous system Most patients presenting with headache have primary headache syndromes Episodic headache: more common Chronic headache: attacks occurring more frequently than 15 days/month for more than 6 months Cont.

6. 6 <2% of headaches in primary care offices Caused by exogenous disorders: Head trauma Vascular disease Neoplasms Substance abuse or withdrawal Infection/Inflammation Metabolic disorders others II. SECONDARY HEADCHE

7. 7 PRIMARY HEADACHE SYNDROMES Tension type headache Migraine Trigeminal Neuralgia Cluster headache Others

8. 8 I- TENSION TYPE Most common-69% Episodic or chronic Primary disorder of CNS pain modulation seen equally in both sexes

9. 9 Precipitating factors Stress: usually occurs in the afternoon after long stressful work hours or after an exam Sleep deprivation Uncomfortable stressful position and/or bad posture Irregular meal time (hunger) Eyestrain Caffeine withdrawal Dehydration

10. 10 Symptoms & Signs Gradual onset , radiate forward from occiput Bilateral, dull, tight, band like pain Less in morning, pain increase as day goes on No accompanying N,V, throbbing, sensitivity to light, sound or movement

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12. 12 Management Paracetamol,Aspirin,NSAIDs Behavioral approach-relaxation Chronic-amitriptyline

13. 13 II- MIGRAINE 2nd most common-16% 15% women and 6% men Severe, episodic, unilateral,throbbing pain Nausea,Vomiting Sensitivity to light ,sound, movement Genetic predisposition

14. 14 Pathophysiology Different theories suggest different causes Vascular theory : vasoconstriction followed by vasodilation with resulting in changes in blood flow causes the throbbing pain . Second theory : pain results from muscular tension Biochemical changes: changes in serotonin level

15. 15 Triggers Flashing lights , Loud sounds , Strong odors Stress Hunger Fatigue Smoking Menstruation , Pregnancy , Menopause , Oral Contraceptives Sleep changes Caffeine ,Chocolate ,Tyramine

16. 16 Classical Migraine or Migraine with AURA Symptom Triad Paroxysmal headache nausea &/or vomiting aura of focal neurological events(visual) 20-25%

17. 17 AURA: Flashing lights, silvery zigzag lines moving across visual field over a period of 20 minutes Sometimes leaving a trail of temporary visual field loss Sometimes-Auditory ,Olfactory, gustatory hallucinations Sensory aura-spreading front of tingling and numbness, from one body part to another

18. 18 Common Migraine or Migraine without AURA Paroxysmal headache Vomiting +/- NO AURA

19. 19 Diagnosis Simplified Diagnostic Criteria for MIGRAINE At least 2 of the following + At least 1 of the following: Unilateral pain Throbbing pain Aggravation by movement Moderate or severe intensity Nausea/ vomitting Photophobia and phonophobia

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21. 21 Management Non drug treatmenr Preventive therapy Abortive therapy

22. 22 Management Non drug treatment Avoid headache triggers: foods, drugs, activities Avoid frequent abortive treatment Stop smoking Normalize sleeping and eating Exercise Relaxation and biofeedback Psychotherapy

23. 23 Management Preventive Treatment Tricyclic antidepressants (first-line) Amitriptyline Beta-blockers (first-line) Atenolol, nadolol Ca++ channel blockers – less effective Verapamil most commonly used

24. 24 Management Preventive Treatment Anticonvulsants (second-line; valuable) Valproate and topiramate are quite effective Gabapentin Lamotrigine, levetiracetam Pregabalin

25. 25 Management Preventive Treatment Ergots: Rarely used for prevention Side effects may be problematic Methysergide : fibrosis (use 6 months max) MAOIs: Can be very effective Tyramine-free diet a must Numerous drug interactions

26. 26 Management Abortive Treatment Simple and combined analgesics e.g NSAIDs. Mixed analgesics (barbiturate plus simple analgesics) Ergot derivatives Triptans Opioids

27. 27 Management Triptans: Serotonin 5-HT1 agonists Reduce neurogenic inflammation Most effective if used at onset of headache or aura, though may be helpful at other phases Used specifically for migraine For nonresponders , try ergots (also act on NE, DA, other receptors)

28. 28 Management Other Agents Antiemetics/Neuroleptics: often combined with abortive agents Prochlorperazine, hydroxyzine, promethazine, metoclopramide

29. 29 Drugs To Avoid Butorphanol nasal spray Meperidine Overuse of any short-acting analgesic (opioids, triptans)

30. 30 III- Trigeminal Neuralgia Lancinating pain in 2 nd and 3 rd divisions of trigeminal nerve >50yrs Severe, brief ,repetitive pain causing patient to flinch Precipitated by touching trigger zones: washing, shaving, eating, cold wind

31. 31 Pathophysiology Compression of trigeminal N by aberrant loop of cerebellar arteries as nerve enters brainstem Other benign compressive lesions Multiple sclerosis: occurs due to plaque of demyelination in trigeminal root entry zone

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33. 33 Management Carbamazepine Intolerant-Gabapentin/Pregabalin Injection of alcohol into peripheral branch of nerve Posterior craniotomy to relieve vascular compression of trigeminal nerve

34. 34 IV- CLUSTER HEADACHE Headaches occur during a short time span. The cluster then recurs periodically. A typical cluster of headaches may last 4-8weeks with 1-2 headaches/day during the cluster. Patient may be free 6months to 1year before another cluster of headache occurs. Male to Female ratio 5:1

35. 35 Symptoms & Signs Abrupt onset of headache originating in the eye and spreading over the temporal area. Pain extremely severe and last 20-60minutes The headache associated with Nasal stuffiness Rhinorrhoea Redness of the Eye Flush and edema of the cheek

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37. 37 Management Acute: Oxygen inhalation 100% Triptans/ergots Indomethacin

38. 38 Management Chronic/Preventive: Verapamil, lithium Valproate, topiramate Prednisone burst Melatonin Ergots

39. 39 Medication Overuse Headache Persistent, recurring headache in the setting of regular analgesic use Continues until medication is stopped Often responsible for “transformation” of episodic into chronic headache

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